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Kimlinger MJ, No TJ, Mace EH, Delgado RD, Lopez MG, de Caestecker MP, Billings FT. Hyperoxia Increases Kidney Injury During Renal Ischemia and Reperfusion in Mice. Anesth Analg 2023; 137:996-1006. [PMID: 37678264 PMCID: PMC10592523 DOI: 10.1213/ane.0000000000006600] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 09/09/2023]
Abstract
BACKGROUND Renal ischemia and reperfusion (IR) contribute to perioperative acute kidney injury, and oxygen is a key regulator of this process. We hypothesized that oxygen administration during surgery and renal IR would impact postoperative kidney function and injury in mice. METHODS Mice were anesthetized, intubated, and mechanically ventilated with a fraction of inspired oxygen (F io2 ) 0.10 (hypoxia), 0.21 (normoxia), 0.60 (moderate hyperoxia), or 1.00 (severe hyperoxia) during 67 minutes of renal IR or sham IR surgery. Additional mice were treated before IR or sham IR surgery with 50 mg/kg tempol, a superoxide scavenger. At 24 hours, mice were sacrificed, and blood and kidney collected. We assessed and compared kidney function and injury across groups by measuring blood urea nitrogen (BUN, primary end point), renal histological injury, renal expression of neutrophil gelatinase-associated lipocalin (NGAL), and renal heme oxygenase 1 ( Ho-1 ), peroxisome proliferator-activated receptor gamma coactivator 1-α ( Pgc1-α ), and glutathione peroxidase 4 ( Gpx-4 ) transcripts, to explore potential mechanisms of any effect of oxygen. RESULTS Hyperoxia and hypoxia during renal IR surgery decreased renal function and increased kidney injury compared to normoxia. Baseline median (interquartile range) BUN was 22.2 mg/dL (18.4-26.0), and 24 hours after IR surgery, BUN was 17.5 mg/dL (95% confidence interval [CI], 1.3-38.4; P = .034) higher in moderate hyperoxia-treated animals, 51.8 mg/dL (95% CI, 24.9-74.8; P < .001) higher in severe hyperoxia-treated animals, and 64.9 mg/dL (95% CI, 41.2-80.3; P < .001) higher in hypoxia-treated animals compared to animals treated with normoxia ( P < .001, overall effect of hyperoxia). Hyperoxia-induced injury, but not hypoxia-induced injury, was attenuated by pretreatment with tempol. Histological injury scores, renal NGAL staining, and renal transcription of Ho-1 and suppression of Pgc1- α followed the same pattern as BUN, in relation to the effects of oxygen treatment. CONCLUSIONS In this controlled preclinical study of oxygen treatment during renal IR surgery, hyperoxia and hypoxia impaired renal function, increased renal injury, and impacted expression of genes that affect mitochondrial biogenesis and antioxidant response. These results might have implications for patients during surgery when high concentrations of oxygen are frequently administered, especially in cases involving renal IR.
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Hu W, Li W, Mangal R, Jia M, Ji X, Ding Y. Normobaric Hyperoxia (NBHO): An Adjunctive Therapy to Cerebrovascular Recanalization in Ischemic Stroke. Aging Dis 2023; 14:1483-1487. [PMID: 37196114 PMCID: PMC10529751 DOI: 10.14336/ad.2023.0227] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/25/2022] [Accepted: 02/26/2023] [Indexed: 05/19/2023] Open
Abstract
Acute ischemic stroke (AIS) is a serious neurological disease. Normobaric hyperoxia (NBHO) is both a non-invasive and easy method that seems to be able to improve outcomes after cerebral ischemia/reperfusion. In clinical trials, normal low-flow oxygen has been shown to be ineffective, but NBHO has been shown to have a transient brain-protective effect. Today, NBHO combined with recanalization is the best treatment available. NBHO combined with thrombolysis is considered to improve neurological scores and long-term outcomes. Large randomized controlled trials (RCTs), however, are still needed to determine the role they will have in stroke treatment. RCTs of NBHO combined with thrombectomy have both improved infarct volume at 24 hours and the long-term prognosis. These two mechanisms most likely play key roles in the neuroprotective actions of NBHO after recanalization, including the increase in penumbra oxygen supply and the integrity of the blood-brain barrier (BBB). Considering the mechanism of action of NBHO, oxygen should be given as early as possible to increase the duration of oxygen therapy before recanalization is initiated. NBHO can further prolong the existence time of penumbra, so that more patients may benefit from it. Overall, however, recanalization therapy is still essential.
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Affiliation(s)
- Wenbo Hu
- Department of Neurology, Xuanwu Hospital, Capital Medical University, Beijing, China.
| | - Weili Li
- Cerebrovascular Diseases Research Institute, Xuanwu Hospital, Capital Medical University, Beijing, China.
- Beijing Institute of Brain Disorders, Capital Medical University, Beijing, China.
| | - Ruchi Mangal
- Department of Neurosurgery, Wayne State University School of Medicine, Michigan, USA.
| | - Milan Jia
- Department of Neurology, Xuanwu Hospital, Capital Medical University, Beijing, China.
| | - Xunming Ji
- Department of Neurology, Xuanwu Hospital, Capital Medical University, Beijing, China.
- Beijing Institute of Brain Disorders, Capital Medical University, Beijing, China.
- Beijing Key Laboratory of Hypoxic Conditioning Translational Medicine, Xuanwu Hospital, Capital Medical University, Beijing, China.
| | - Yuchuan Ding
- Department of Neurosurgery, Wayne State University School of Medicine, Michigan, USA.
- John D. Dingell VA Medical Center, Detroit, Michigan, USA.
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Mace EH, Kimlinger MJ, Billings FT, Lopez MG. Targeting Soluble Guanylyl Cyclase during Ischemia and Reperfusion. Cells 2023; 12:1903. [PMID: 37508567 PMCID: PMC10378692 DOI: 10.3390/cells12141903] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/31/2023] [Accepted: 07/17/2023] [Indexed: 07/30/2023] Open
Abstract
Ischemia and reperfusion (IR) damage organs and contribute to many disease states. Few effective treatments exist that attenuate IR injury. The augmentation of nitric oxide (NO) signaling remains a promising therapeutic target for IR injury. NO binds to soluble guanylyl cyclase (sGC) to regulate vasodilation, maintain endothelial barrier integrity, and modulate inflammation through the production of cyclic-GMP in vascular smooth muscle. Pharmacologic sGC stimulators and activators have recently been developed. In preclinical studies, sGC stimulators, which augment the reduced form of sGC, and activators, which activate the oxidized non-NO binding form of sGC, increase vasodilation and decrease cardiac, cerebral, renal, pulmonary, and hepatic injury following IR. These effects may be a result of the improved regulation of perfusion and decreased oxidative injury during IR. sGC stimulators are now used clinically to treat some chronic conditions such as heart failure and pulmonary hypertension. Clinical trials of sGC activators have been terminated secondary to adverse side effects including hypotension. Additional clinical studies to investigate the effects of sGC stimulation and activation during acute conditions, such as IR, are warranted.
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Affiliation(s)
- Eric H Mace
- Department of Surgery, Vanderbilt University Medical Center, Medical Center North, Suite CCC-4312, 1161 21st Avenue South, Nashville, TN 37232-2730, USA
| | - Melissa J Kimlinger
- Vanderbilt University School of Medicine, 428 Eskind Family Biomedical Library and Learning Center, Nashville, TN 37240-0002, USA
| | - Frederic T Billings
- Department of Anesthesiology, Division of Critical Care Medicine, Vanderbilt University Medical Center, Medical Arts Building, Suite 422, 1211 21st Avenue South, Nashville, TN 37212-1750, USA
| | - Marcos G Lopez
- Department of Anesthesiology, Division of Critical Care Medicine, Vanderbilt University Medical Center, Medical Arts Building, Suite 422, 1211 21st Avenue South, Nashville, TN 37212-1750, USA
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Sugimoto K, Yang J, Fischer P, Takizawa T, Mulder I, Qin T, Erdogan TD, Yaseen MA, Sakadžić S, Chung DY, Ayata C. Optogenetic Spreading Depolarizations Do Not Worsen Acute Ischemic Stroke Outcome. Stroke 2023; 54:1110-1119. [PMID: 36876481 PMCID: PMC10050120 DOI: 10.1161/strokeaha.122.041351] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/17/2022] [Accepted: 02/01/2023] [Indexed: 03/07/2023]
Abstract
BACKGROUND Spreading depolarizations (SDs) are believed to contribute to injury progression and worsen outcomes in focal cerebral ischemia because exogenously induced SDs have been associated with enlarged infarct volumes. However, previous studies used highly invasive methods to trigger SDs that can directly cause tissue injury (eg, topical KCl) and confound the interpretation. Here, we tested whether SDs indeed enlarge infarcts when induced via a novel, noninjurious method using optogenetics. METHODS Using transgenic mice expressing channelrhodopsin-2 in neurons (Thy1-ChR2-YFP), we induced 8 optogenetic SDs to trigger SDs noninvasively at a remote cortical location in a noninjurious manner during 1-hour distal microvascular clip or proximal an endovascular filament occlusion of the middle cerebral artery. Laser speckle imaging was used to monitor cerebral blood flow. Infarct volumes were then quantified at 24 or 48 hours. RESULTS Infarct volumes in the optogenetic SD arm did not differ from the control arm in either distal or proximal middle cerebral artery occlusion, despite a 6-fold and 4-fold higher number of SDs, respectively. Identical optogenetic illumination in wild-type mice did not affect the infarct volume. Full-field laser speckle imaging showed that optogenetic stimulation did not affect the perfusion in the peri-infarct cortex. CONCLUSIONS Altogether, these data show that SDs induced noninvasively using optogenetics do not worsen tissue outcomes. Our findings compel a careful reexamination of the notion that SDs are causally linked to infarct expansion.
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Affiliation(s)
- Kazutaka Sugimoto
- Department of Radiology, Massachusetts General Hospital, Harvard Medical School, Charlestown, MA 02129
- Department of Neurosurgery, Yamaguchi University School of Medicine, Ube, Yamaguchi 7558505, Japan
| | - Joanna Yang
- Department of Radiology, Massachusetts General Hospital, Harvard Medical School, Charlestown, MA 02129
| | - Paul Fischer
- Department of Radiology, Massachusetts General Hospital, Harvard Medical School, Charlestown, MA 02129
| | - Tsubasa Takizawa
- Department of Radiology, Massachusetts General Hospital, Harvard Medical School, Charlestown, MA 02129
| | - Inge Mulder
- Department of Radiology, Massachusetts General Hospital, Harvard Medical School, Charlestown, MA 02129
| | - Tao Qin
- Department of Radiology, Massachusetts General Hospital, Harvard Medical School, Charlestown, MA 02129
| | - Taylan D. Erdogan
- Department of Radiology, Massachusetts General Hospital, Harvard Medical School, Charlestown, MA 02129
| | - Mohammad A. Yaseen
- Martinos Center for Biomedical Imaging, Massachusetts General Hospital, Charlestown, MA 02129
| | - Sava Sakadžić
- Martinos Center for Biomedical Imaging, Massachusetts General Hospital, Charlestown, MA 02129
| | - David Y. Chung
- Department of Radiology, Massachusetts General Hospital, Harvard Medical School, Charlestown, MA 02129
- Department of Neurology, Massachusetts General Hospital, Harvard Medical School, Boston, MA 02114
| | - Cenk Ayata
- Department of Radiology, Massachusetts General Hospital, Harvard Medical School, Charlestown, MA 02129
- Department of Neurology, Massachusetts General Hospital, Harvard Medical School, Boston, MA 02114
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Impact of Hyperoxia and Hypocapnia on Neurological Outcomes in Patients with Aneurysmal Subarachnoid Hemorrhage: A Retrospective Study. Crit Care Res Pract 2019; 2019:7584573. [PMID: 31885915 PMCID: PMC6925754 DOI: 10.1155/2019/7584573] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/11/2019] [Revised: 11/04/2019] [Accepted: 11/11/2019] [Indexed: 01/13/2023] Open
Abstract
In recent decades, there is increasing evidence suggesting that hyperoxia and hypocapnia are associated with poor outcomes in critically ill patients with cardiac arrest or traumatic brain injury. Yet, the impact of hyperoxia and hypocapnia on neurological outcome in patients with subarachnoid hemorrhage (SAH) has not been well studied. In the present study, we evaluated the impact of hyperoxia and hypocapnia on neurological outcomes in patients with aneurysmal SAH (aSAH). Patients with aSAH who were admitted to the intensive care unit (ICU) of a tertiary hospital in Hong Kong between January 2011 and December 2016 were retrospectively recruited. Patients' demographics, comorbidities, radiological findings, clinical grades of SAH, PO2, and PCO2 within 24 hours of ICU admission, and Glasgow Outcome Scale (GOS) at 3 months after admission were recorded. Patients with a GOS score of 3 or less were considered having poor neurological outcomes. Among the 244 patients with aSAH, 122 of them (50%) had poor neurological outcomes at 3 months. Early hyperoxia (PO2 > 200 mmHg) and hypercapnia (PCO2 > 45 mmHg) were more common among patients with poor neurological outcomes. Logistic regression analysis indicated that hyperoxia independently predicted poor neurological outcomes (OR 3.788, 95% CI 1.131-12.690, P=0.031). Classification tree analysis revealed that hypocapnia was associated with poor neurological outcomes in patients who were less critically ill (APACHE < 50) and without concomitant intracranial hemorrhage (ICH) or intraventricular hemorrhage (IVH) (adjusted P=0.006, χ 2 = 7.452). These findings suggested that hyperoxia and hypocapnia may be associated with poor neurological outcomes in patients with aSAH.
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Shu Z, Tan J, Miao Y, Zhang Q. The role of microvesicles containing microRNAs in vascular endothelial dysfunction. J Cell Mol Med 2019; 23:7933-7945. [PMID: 31576661 PMCID: PMC6850938 DOI: 10.1111/jcmm.14716] [Citation(s) in RCA: 35] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/21/2019] [Revised: 08/28/2019] [Accepted: 09/01/2019] [Indexed: 12/21/2022] Open
Abstract
Many studies have shown that endothelial dysfunction is associated with a variety of cardiovascular diseases. The endothelium is one of the primary targets of circulating microvesicles. Besides, microRNAs emerge as important regulators of endothelial cell function. As a delivery system of microRNAs, microvesicles play an active and important role in regulating vascular endothelial function. In recent years, some studies have shown that microvesicles containing microRNAs regulate the pathophysiological changes in vascular endothelium, such as cell apoptosis, proliferation, migration and inflammation. These studies have provided some clues for the possible roles of microvesicles and microRNAs in vascular endothelial dysfunction‐associated diseases, and opened the door towards discovering potential novel therapeutic targets. In this review, we provide an overview of the main characteristics of microvesicles and microRNAs, summarizing their potential role and mechanism in endothelial dysfunction, and discussing the clinical application and existing problems of microvesicles for better translational applications.
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Affiliation(s)
- Zeyu Shu
- Department of Geriatrics, Tianjin Medical University General Hospital, Tianjin Geriatrics Institute, Tianjin, China
| | - Jin Tan
- Department of Geriatrics, Tianjin Medical University General Hospital, Tianjin Geriatrics Institute, Tianjin, China
| | | | - Qiang Zhang
- Department of Geriatrics, Tianjin Medical University General Hospital, Tianjin Geriatrics Institute, Tianjin, China
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Baron JC. Protecting the ischaemic penumbra as an adjunct to thrombectomy for acute stroke. Nat Rev Neurol 2019; 14:325-337. [PMID: 29674752 DOI: 10.1038/s41582-018-0002-2] [Citation(s) in RCA: 106] [Impact Index Per Article: 21.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
Abstract
After ischaemic stroke, brain damage can be curtailed by rescuing the 'ischaemic penumbra' - that is, the severely hypoperfused, at-risk but not yet infarcted tissue. Current evidence-based treatments involve restoration of blood flow so as to salvage the penumbra before it evolves into irreversibly damaged tissue, termed the 'core'. Intravenous thrombolysis (IVT) can salvage the penumbra if given within 4.5 h after stroke onset; however, the early recanalization rate is only ~30%. Direct removal of the occluding clot by mechanical thrombectomy considerably improves outcomes over IVT alone, but despite early recanalization in > 80% of cases, ~50% of patients who receive this treatment do not enjoy functional independence, usually because the core is already too large at the time of recanalization. Novel therapies aiming to 'freeze' the penumbra - that is, prevent core growth until recanalization is complete - hold potential as adjuncts to mechanical thrombectomy. This Review focuses on nonpharmacological approaches that aim to restore the physiological balance between oxygen delivery to and oxygen demand of the penumbra. Particular emphasis is placed on normobaric oxygen therapy, hypothermia and sensory stimulation. Preclinical evidence and early pilot clinical trials are critically reviewed, and future directions, including clinical translation and trial design issues, are discussed.
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Affiliation(s)
- Jean-Claude Baron
- Department of Neurology, Hôpital Sainte-Anne, Université Paris 5, INSERM U894, Paris, France.
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Yang C, Fan F, Sawmiller D, Tan J, Wang Q, Xiang Y. C1q/TNF‐related protein 9: A novel therapeutic target in ischemic stroke? J Neurosci Res 2018; 97:128-136. [PMID: 30378715 DOI: 10.1002/jnr.24353] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/19/2018] [Revised: 10/03/2018] [Accepted: 10/10/2018] [Indexed: 12/18/2022]
Affiliation(s)
- Cui Yang
- Department of Clinical MedicineChengdu Medical College Chengdu China
- Department of Neurology Chengdu Military General Hospital Chengdu China
| | - Fan Fan
- Department of Clinical MedicineChengdu Medical College Chengdu China
- Department of Neurology Chengdu Military General Hospital Chengdu China
| | - Darrell Sawmiller
- Neuroimmunology Laboratory, Department of Psychiatry and Behavioral Neurosciences, Morsani College of Medicine University of South Florida Tampa FL
| | - Jun Tan
- Neuroimmunology Laboratory, Department of Psychiatry and Behavioral Neurosciences, Morsani College of Medicine University of South Florida Tampa FL
| | - Qingsong Wang
- Department of Neurology Chengdu Military General Hospital Chengdu China
| | - Yang Xiang
- Department of Neurology Chengdu Military General Hospital Chengdu China
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Klass A, Sánchez-Porras R, Santos E. Systematic review of the pharmacological agents that have been tested against spreading depolarizations. J Cereb Blood Flow Metab 2018; 38:1149-1179. [PMID: 29673289 PMCID: PMC6434447 DOI: 10.1177/0271678x18771440] [Citation(s) in RCA: 34] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
Spreading depolarization (SD) occurs alongside brain injuries and it can lead to neuronal damage. Therefore, pharmacological modulation of SD can constitute a therapeutic approach to reduce its detrimental effects and to improve the clinical outcome of patients. The major objective of this article was to produce a systematic review of all the drugs that have been tested against SD. Of the substances that have been examined, most have been shown to modulate certain SD characteristics. Only a few have succeeded in significantly inhibiting SD. We present a variety of strategies that have been proposed to overcome the notorious harmfulness and pharmacoresistance of SD. Information on clinically used anesthetic, sedative, hypnotic agents, anti-migraine drugs, anticonvulsants and various other substances have been compiled and reviewed with respect to the efficacy against SD, in order to answer the question of whether a drug at safe doses could be of therapeutic use against SD in humans.
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Affiliation(s)
- Anna Klass
- Neurosurgery Department, University of Heidelberg, Heidelberg, Germany
| | | | - Edgar Santos
- Neurosurgery Department, University of Heidelberg, Heidelberg, Germany
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10
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Role of Nitric Oxide and Hydrogen Sulfide in Ischemic Stroke and the Emergent Epigenetic Underpinnings. Mol Neurobiol 2018; 56:1749-1769. [PMID: 29926377 DOI: 10.1007/s12035-018-1141-6] [Citation(s) in RCA: 41] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/23/2017] [Accepted: 05/22/2018] [Indexed: 02/06/2023]
Abstract
Nitric oxide (NO) and hydrogen sulfide (H2S) are the key gasotransmitters with an imperious role in the maintenance of cerebrovascular homeostasis. A decline in their levels contributes to endothelial dysfunction that portends ischemic stroke (IS) or cerebral ischemia/reperfusion (CI/R). Nevertheless, their exorbitant production during CI/R is associated with exacerbation of cerebrovascular injury in the post-stroke epoch. NO-producing nitric oxide synthases are implicated in IS pathology and their activity is regulated, inter alia, by various post-translational modifications and chromatin-based mechanisms. These account for heterogeneous alterations in NO production in a disease setting like IS. Interestingly, NO per se has been posited as an endogenous epigenetic modulator. Further, there is compelling evidence for an ingenious crosstalk between NO and H2S in effecting the canonical (direct) and non-canonical (off-target collateral) functions. In this regard, NO-mediated S-nitrosylation and H2S-mediated S-sulfhydration of specific reactive thiols in an expanding array of target proteins are the principal modalities mediating the all-pervasive influence of NO and H2S on cell fate in an ischemic brain. An integrated stress response subsuming unfolded protein response and autophagy to cellular stressors like endoplasmic reticulum stress, in part, is entrenched in such signaling modalities that substantiate the role of NO and H2S in priming the cells for stress response. The precis presented here provides a comprehension on the multifarious actions of NO and H2S and their epigenetic underpinnings, their crosstalk in maintenance of cerebrovascular homeostasis, and their "Janus bifrons" effect in IS milieu together with plausible therapeutic implications.
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Lan J, Esposito E, Ayata C, Singhal AB, Lo EH, Ji X. Different Effects of Normobaric Oxygen in Normotensive Versus Hypertensive Rats After Focal Cerebral Ischemia. Stroke 2018; 49:1534-1537. [PMID: 29712880 DOI: 10.1161/strokeaha.118.020626] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/19/2018] [Revised: 03/16/2018] [Accepted: 03/22/2018] [Indexed: 11/16/2022]
Abstract
BACKGROUND AND PURPOSE The efficacy of neuroprotective approaches in stroke may be influenced by existing comorbidities. Here, we compared the effects of normobaric hyperoxia (NBO) in normotensive versus hypertensive rats subjected to transient focal cerebral ischemia. METHODS Male Sprague-Dawley and spontaneously hypertensive rats were subjected to transient focal ischemia via intraluminal filament occlusions of the middle cerebral artery. NBO was started 15 minutes after ischemic onset and stopped at the time of reperfusion. Acute neurological deficits and tetrazolium-stained infarct volumes were quantified at 24 hours. RESULTS NBO reduced mean infarct volumes by ≈50% (P=0.0064) in normotensive Sprague-Dawley rats subjected to 100 minutes transient ischemia. No effects of NBO were observed in hypertensive spontaneously hypertensive rats subjected to either 100 minutes or 75 minutes of transient ischemia. No significant changes in neurological outcomes were detectable in any group. CONCLUSIONS NBO reduced infarction in Sprague-Dawley but not in spontaneously hypertensive rats. These findings suggest that comorbidities may influence responses to potential treatments after stroke.
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Affiliation(s)
- Jing Lan
- From the Department of Neurology, China-America Institute of Neuroscience, Xuanwu Hospital, Capital Medical University, Beijing (J.L., X.J.)
- Departments of Radiology (J.L., E.E., E.H.L.)
| | - Elga Esposito
- Departments of Radiology (J.L., E.E., E.H.L.)
- Neurology (E.E., C.A., A.B.S., E.H.L.), Massachusetts General Hospital, Harvard Medical School, Boston
| | - Cenk Ayata
- Neurology (E.E., C.A., A.B.S., E.H.L.), Massachusetts General Hospital, Harvard Medical School, Boston
| | - Aneesh B Singhal
- Neurology (E.E., C.A., A.B.S., E.H.L.), Massachusetts General Hospital, Harvard Medical School, Boston
| | - Eng H Lo
- Departments of Radiology (J.L., E.E., E.H.L.)
- Neurology (E.E., C.A., A.B.S., E.H.L.), Massachusetts General Hospital, Harvard Medical School, Boston
| | - Xunming Ji
- From the Department of Neurology, China-America Institute of Neuroscience, Xuanwu Hospital, Capital Medical University, Beijing (J.L., X.J.)
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12
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Ding J, Zhou D, Sui M, Meng R, Chandra A, Han J, Ding Y, Ji X. The effect of normobaric oxygen in patients with acute stroke: a systematic review and meta-analysis. Neurol Res 2018; 40:433-444. [PMID: 29600891 DOI: 10.1080/01616412.2018.1454091] [Citation(s) in RCA: 24] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
Background Normobaric oxygen (NBO) has received considerable attention due to controversial data in brain protection in patients with acute stroke. This study aims to analyze current data of NBO on brain protection as used in the clinic. Methods We searched for and reviewed relevant articles and references from Pubmed, Medline, Embase, Cochrane, and Clincialtrials.gov that were published prior to October 2017. Data from prospective studies were processed using RevMan5.0 software, provided by Cochrane collaboration and transformed using relevant formulas. Results A total of 11 prospective RCT studies including 6366 patients with acute stroke (NBO group, 3207; control group, 3159) were enrolled in this analysis. △NIHSS represented the values of NIHSS at 4, 24 h, or 7 days post-stroke minus baseline NIHSS. Compared to controls, there was a minor trend toward NBO benefits in short-term prognostic indices, as indicated by decreased ΔNIHSS at our defined time points. By contrast, NBO decreased Barthel Index scores between 3 and 7 months, and increased death rates at 3, 6 months, and 1 year, whereas, modified Rankin Scale scores between 3 and 6 months were unchanged. Conclusions The existing trends toward benefits revealed in this meta-analysis help us appreciate the promising value of NBO, although current evidence of NBO on improving clinical outcomes of stroke is insufficient. Well-designed multi-center clinical trials are encouraged and urgently needed to further explore the efficacy of NBO on brain protection.
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Affiliation(s)
- Jiayue Ding
- a Department of Neurology , Xuanwu Hospital, Capital Medical University , Beijing , China.,b Beijing Institute for Brain Disorders , Beijing , China
| | - Da Zhou
- a Department of Neurology , Xuanwu Hospital, Capital Medical University , Beijing , China.,b Beijing Institute for Brain Disorders , Beijing , China
| | - Meng Sui
- c Department of Economics , Fordham University , Bronx , NY , USA
| | - Ran Meng
- a Department of Neurology , Xuanwu Hospital, Capital Medical University , Beijing , China.,b Beijing Institute for Brain Disorders , Beijing , China
| | - Ankush Chandra
- d Department of Neurosurgery , Wayne State University School of Medicine , Detroit , MI , USA.,e Department of Neurosurgery , University of California San Francisco , San Francisco, CA , USA
| | - Jie Han
- f Department of Neurology , The First Affiliated Hospital of Dalian Medical University , Dalian , China
| | - Yuchuan Ding
- d Department of Neurosurgery , Wayne State University School of Medicine , Detroit , MI , USA
| | - Xunming Ji
- b Beijing Institute for Brain Disorders , Beijing , China.,g Department of Neurosurgery , Xuanwu Hospital, Capital Medical University , Beijing , China
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13
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Choi ES, Yoon JJ, Han BH, Jeong DH, Lee YJ, Kang DG, Lee HS. Ligustilide attenuates vascular inflammation and activates Nrf2/HO-1 induction and, NO synthesis in HUVECs. PHYTOMEDICINE : INTERNATIONAL JOURNAL OF PHYTOTHERAPY AND PHYTOPHARMACOLOGY 2018; 38:12-23. [PMID: 29425644 DOI: 10.1016/j.phymed.2017.09.022] [Citation(s) in RCA: 67] [Impact Index Per Article: 11.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/13/2017] [Revised: 06/20/2017] [Accepted: 09/30/2017] [Indexed: 06/08/2023]
Abstract
BACKGROUND Ligustilide is a bioactive phthalide derivative isolated from Cnidii Rhizoma (Cnidium officinale, rhizome) and Angelicae Gigantis Radix (Angelica gigas Nakai, root) which are both medicinal herbs used to treat circulatory disorders. Vascular endothelium is a central spot in developing cardiovascular diseases and chronic vascular inflammation might result in atherosclerosis development. PURPOSE We previously found out that a traditional herbal formula, Samul-Tang (Si-Wu-Tang, containing Cnidii Rhizoma and Angelicae Gigantis Radix), attenuated vascular inflammation in human umbilical vein endothelial cells (HUVECs). However, which compound was responsible for vascular protective action remained unclear. Here, we investigated vascular protective potential of an isolated single compound, (Z)-ligustilide. METHODS MTT assay, western blotting, immunofluorescence, electrophoretic mobility shift assay was performed. BCECF-AM, CM-H2DCFDA, DAF-FM diacetate were used as a fluorescent indicator. RESULTS Ligustilide suppressed HL-60 monocyte adhesion and CAMs (ICAM-1, VCAM-1, E-selectin) expression in HUVECs. Ligustilide significantly inhibited TNF-α-increased production of ROS and activated NF-κB signaling pathway. Also, ligustilide treated HUVECs exhibited significant HO-1 induction via Nrf2 nuclear translocation and endothelial NO synthesis. CONCLUSION Present study demonstrates that ligustilde attenuates vascular inflammation and activate defense system of endothelial cell. Ligustilide is a bioactive compound which might prevent cardiovascular complications such as thrombosis or atherosclerosis.
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Affiliation(s)
- Eun Sik Choi
- College of Oriental Medicine and Professional Graduate School of Oriental Medicine, Wonkwang University, 460 Iksandae-ro, Jeonbuk 54538, Republic of Korea; Hanbang Cardio-Renal Syndrome Research Center, Wonkwang University, 460 Iksandae-ro, Jeonbuk 54538, Republic of Korea
| | - Jung Joo Yoon
- College of Oriental Medicine and Professional Graduate School of Oriental Medicine, Wonkwang University, 460 Iksandae-ro, Jeonbuk 54538, Republic of Korea; Hanbang Cardio-Renal Syndrome Research Center, Wonkwang University, 460 Iksandae-ro, Jeonbuk 54538, Republic of Korea
| | - Byung Hyuk Han
- College of Oriental Medicine and Professional Graduate School of Oriental Medicine, Wonkwang University, 460 Iksandae-ro, Jeonbuk 54538, Republic of Korea; Hanbang Cardio-Renal Syndrome Research Center, Wonkwang University, 460 Iksandae-ro, Jeonbuk 54538, Republic of Korea
| | - Da Hye Jeong
- College of Oriental Medicine and Professional Graduate School of Oriental Medicine, Wonkwang University, 460 Iksandae-ro, Jeonbuk 54538, Republic of Korea; Hanbang Cardio-Renal Syndrome Research Center, Wonkwang University, 460 Iksandae-ro, Jeonbuk 54538, Republic of Korea
| | - Yun Jung Lee
- College of Oriental Medicine and Professional Graduate School of Oriental Medicine, Wonkwang University, 460 Iksandae-ro, Jeonbuk 54538, Republic of Korea; Hanbang Cardio-Renal Syndrome Research Center, Wonkwang University, 460 Iksandae-ro, Jeonbuk 54538, Republic of Korea
| | - Dae Gill Kang
- College of Oriental Medicine and Professional Graduate School of Oriental Medicine, Wonkwang University, 460 Iksandae-ro, Jeonbuk 54538, Republic of Korea; Hanbang Cardio-Renal Syndrome Research Center, Wonkwang University, 460 Iksandae-ro, Jeonbuk 54538, Republic of Korea.
| | - Ho Sub Lee
- College of Oriental Medicine and Professional Graduate School of Oriental Medicine, Wonkwang University, 460 Iksandae-ro, Jeonbuk 54538, Republic of Korea; Hanbang Cardio-Renal Syndrome Research Center, Wonkwang University, 460 Iksandae-ro, Jeonbuk 54538, Republic of Korea.
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Zhang H, Barralet JE. Mimicking oxygen delivery and waste removal functions of blood. Adv Drug Deliv Rev 2017; 122:84-104. [PMID: 28214553 DOI: 10.1016/j.addr.2017.02.001] [Citation(s) in RCA: 31] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/23/2016] [Revised: 02/13/2017] [Accepted: 02/13/2017] [Indexed: 12/20/2022]
Abstract
In addition to immunological and wound healing cell and platelet delivery, ion stasis and nutrient supply, blood delivers oxygen to cells and tissues and removes metabolic wastes. For decades researchers have been trying to develop approaches that mimic these two immediately vital functions of blood. Oxygen is crucial for the long-term survival of tissues and cells in vertebrates. Hypoxia (oxygen deficiency) and even at times anoxia (absence of oxygen) can occur during organ preservation, organ and cell transplantation, wound healing, in tumors and engineering of tissues. Different approaches have been developed to deliver oxygen to tissues and cells, including hyperbaric oxygen therapy (HBOT), normobaric hyperoxia therapy (NBOT), using biochemical reactions and electrolysis, employing liquids with high oxygen solubility, administering hemoglobin, myoglobin and red blood cells (RBCs), introducing oxygen-generating agents, using oxygen-carrying microparticles, persufflation, and peritoneal oxygenation. Metabolic waste accumulation is another issue in biological systems when blood flow is insufficient. Metabolic wastes change the microenvironment of cells and tissues, influence the metabolic activities of cells, and ultimately cause cell death. This review examines advances in blood mimicking systems in the field of biomedical engineering in terms of oxygen delivery and metabolic waste removal.
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Huang S, Tong X, Rehman MU, Wang M, Zhang L, Wang L, Li J, Yang S. Oxygen Supplementation Ameliorates Tibial Development via Stimulating Vascularization in Tibetan Chickens at High Altitudes. Int J Biol Sci 2017; 13:1547-1559. [PMID: 29230103 PMCID: PMC5723921 DOI: 10.7150/ijbs.22670] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/04/2017] [Accepted: 10/15/2017] [Indexed: 12/20/2022] Open
Abstract
Tibetan chickens (TBCs) living in high-altitude hypoxic environment, are characterized by delayed growth and small size as compared to low-altitude broiler chickens. Increasing evidences signify the beneficial effect of oxygen (O2) supplementation in animal's body for regulating their body growth and organ development. However, it is still unclear that whether O2 supplementation has an ameliorative and protective role in TBCs living at high altitude. In this study, we first found that O2 supplementation not only increased the survival rate but also promoted the growth of TBCs associated with bone development. Importantly, we observed that the increase of vascular distribution in the tibial hypertrophic zone could contribute to promote growth and development of the tibia, which is highly correlated with the up-regulated expression level of vascular endothelial growth factor (VEGF)-A and VEGF receptor-1 (VEGFR1). Additionally, hypoxia inducible factor (HIF)-1ɑ also has a stimulative elevation by O2 supplementation. These results were confirmed by histology, immunohistochemistry, qRT-PCR and Western blotting techniques. Altogether, these findings demonstrated that the up-regulation of VEGFA and its receptors are accompanied by proangiogeneic factor (HIF-1α) expression, which were required for angiogenesis to meliorate tibia development of TBCs in hypoxia-induced bone suppression that occurred during O2 supplementation. Thus, O2 supplementation may serve as a good applicant for promoting and meliorating bone development in juvenile high-altitude animals.
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Affiliation(s)
- Shucheng Huang
- College of Veterinary Medicine, Huazhong Agricultural University, Wuhan 430070, People's Republic of China
| | - Xiaole Tong
- College of Veterinary Medicine, Huazhong Agricultural University, Wuhan 430070, People's Republic of China
| | - Mujeeb Ur Rehman
- College of Veterinary Medicine, Huazhong Agricultural University, Wuhan 430070, People's Republic of China
| | - Meng Wang
- College of Veterinary Medicine, Huazhong Agricultural University, Wuhan 430070, People's Republic of China
| | - Lihong Zhang
- College of Veterinary Medicine, Huazhong Agricultural University, Wuhan 430070, People's Republic of China
| | - Lei Wang
- College of Veterinary Medicine, Huazhong Agricultural University, Wuhan 430070, People's Republic of China
| | - Jiakui Li
- College of Veterinary Medicine, Huazhong Agricultural University, Wuhan 430070, People's Republic of China.,College of Animals Husbandry and Veterinary Medicine, Tibet Agricultural and Animal Husbandry University, Nyingchi 860000 Tibet, People's Republic of China
| | - Shijin Yang
- College of Veterinary Medicine, Huazhong Agricultural University, Wuhan 430070, People's Republic of China
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16
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Effects of hyperoxia on 18F-fluoro-misonidazole brain uptake and tissue oxygen tension following middle cerebral artery occlusion in rodents: Pilot studies. PLoS One 2017; 12:e0187087. [PMID: 29091934 PMCID: PMC5665507 DOI: 10.1371/journal.pone.0187087] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/25/2017] [Accepted: 10/15/2017] [Indexed: 12/11/2022] Open
Abstract
PURPOSE Mapping brain hypoxia is a major goal for stroke diagnosis, pathophysiology and treatment monitoring. 18F-fluoro-misonidazole (FMISO) positron emission tomography (PET) is the gold standard hypoxia imaging method. Normobaric hyperoxia (NBO) is a promising therapy in acute stroke. In this pilot study, we tested the straightforward hypothesis that NBO would markedly reduce FMISO uptake in ischemic brain in Wistar and spontaneously hypertensive rats (SHRs), two rat strains with distinct vulnerability to brain ischemia, mimicking clinical heterogeneity. METHODS Thirteen adult male rats were randomized to distal middle cerebral artery occlusion under either 30% O2 or 100% O2. FMISO was administered intravenously and PET data acquired dynamically for 3hrs, after which magnetic resonance imaging (MRI) and tetrazolium chloride (TTC) staining were carried out to map the ischemic lesion. Both FMISO tissue uptake at 2-3hrs and FMISO kinetic rate constants, determined based on previously published kinetic modelling, were obtained for the hypoxic area. In a separate group (n = 9), tissue oxygen partial pressure (PtO2) was measured in the ischemic tissue during both control and NBO conditions. RESULTS As expected, the FMISO PET, MRI and TTC lesion volumes were much larger in SHRs than Wistar rats in both the control and NBO conditions. NBO did not appear to substantially reduce FMISO lesion size, nor affect the FMISO kinetic rate constants in either strain. Likewise, MRI and TTC lesion volumes were unaffected. The parallel study showed the expected increases in ischemic cortex PtO2 under NBO, although these were small in some SHRs with very low baseline PtO2. CONCLUSIONS Despite small samples, the apparent lack of marked effects of NBO on FMISO uptake suggests that in permanent ischemia the cellular mechanisms underlying FMISO trapping in hypoxic cells may be disjointed from PtO2. Better understanding of FMISO trapping processes will be important for future applications of FMISO imaging.
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Zhang X, Liu X, Li Y, Lai J, Zhang N, Ming J, Ma X, Ji Q, Xing Y. Downregulation of microRNA-155 ameliorates high glucose-induced endothelial injury by inhibiting NF-κB activation and promoting HO-1 and NO production. Biomed Pharmacother 2017. [DOI: 10.1016/j.biopha.2017.01.122] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022] Open
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Vascular Protective Role of Samul-Tang in HUVECs: Involvement of Nrf2/HO-1 and NO. EVIDENCE-BASED COMPLEMENTARY AND ALTERNATIVE MEDICINE 2016; 2016:9580234. [PMID: 27366195 PMCID: PMC4913014 DOI: 10.1155/2016/9580234] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 01/11/2016] [Revised: 04/19/2016] [Accepted: 05/05/2016] [Indexed: 12/02/2022]
Abstract
Samul-Tang (Si-Wu-Tang, SMT), composed of four medicinal herbs, is a well-known herbal formula treating hematological disorder or gynecologic disease. However, vascular protective effects of SMT and its molecular mechanisms on the vascular endothelium, known as the central spot of vascular inflammatory process, are not reported. The aim of this study was to investigate vascular protective effects of SMT water extract in human umbilical vein endothelial cells (HUVECs). Water extract of SMT was prepared and identified by HPLC-PDA analysis. Expression of cell adhesion molecules (CAMs) and heme oxygenase-1 (HO-1) and translocation of nuclear factor-kappa B (NF-κB) and nuclear factor-erythroid 2-related factor 2 (Nrf2) were determined by western blot. Nuclear localization of NF-κB and Nrf2 was visualized by immunofluorescence and DNA binding activity of NF-κB was measured. ROS production, HL-60 monocyte adhesion, and intracellular nitric oxide (NO) were also measured using a fluorescent indicator. SMT suppressed NF-κB translocation and activation as well as expression of CAMs, monocyte adhesion, and ROS production induced by TNF-α in HUVECs. SMT treated HUVECs showed upregulation of HO-1 and NO which are responsible for vascular protective action. Our study suggests that SMT, a traditionally used herbal formula, protects the vascular endothelium from inflammation and might be used as a promising vascular protective drug.
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Chung DY, Oka F, Ayata C. Spreading Depolarizations: A Therapeutic Target Against Delayed Cerebral Ischemia After Subarachnoid Hemorrhage. J Clin Neurophysiol 2016; 33:196-202. [PMID: 27258442 PMCID: PMC4894342 DOI: 10.1097/wnp.0000000000000275] [Citation(s) in RCA: 38] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/23/2022] Open
Abstract
Delayed cerebral ischemia is the most feared cause of secondary injury progression after subarachnoid hemorrhage. Initially thought to be a direct consequence of large artery spasm and territorial ischemia, recent data suggests that delayed cerebral ischemia represents multiple concurrent and synergistic mechanisms, including microcirculatory dysfunction, inflammation, and microthrombosis. Among these mechanisms, spreading depolarizations (SDs) are arguably the most elusive and underappreciated in the clinical setting. Although SDs have been experimentally detected and examined since the late 1970s, their widespread occurrence in human brain was not unequivocally demonstrated until relatively recently. We now know that SDs occur with very high incidence in human brain after ischemic or hemorrhagic stroke and trauma, and worsen outcomes by increasing metabolic demand, decreasing blood supply, predisposing to seizure activity, and possibly worsening brain edema. In this review, we discuss the causes and consequences of SDs in injured brain. Although much of our mechanistic knowledge comes from experimental models of focal cerebral ischemia, clinical data suggest that the same principles apply regardless of the mode of injury (i.e., ischemia, hemorrhage, or trauma). The hope is that a better fundamental understanding of SDs will lead to novel therapeutic interventions to prevent SD occurrence and its adverse consequences contributing to injury progression in subarachnoid hemorrhage and other forms of acute brain injury.
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Affiliation(s)
- David Y. Chung
- Neurovascular Research Unit, Department of Radiology, Massachusetts General Hospital, Harvard Medical School, Charlestown, MA
- Stroke Service and Neuroscience Intensive Care Unit, Department of Neurology Massachusetts General Hospital, Harvard Medical School, Boston, MA
| | - Fumiaki Oka
- Neurovascular Research Unit, Department of Radiology, Massachusetts General Hospital, Harvard Medical School, Charlestown, MA
- Department of Neurosurgery, Yamaguchi University School of Medicine, Ube, Japan
| | - Cenk Ayata
- Neurovascular Research Unit, Department of Radiology, Massachusetts General Hospital, Harvard Medical School, Charlestown, MA
- Stroke Service and Neuroscience Intensive Care Unit, Department of Neurology Massachusetts General Hospital, Harvard Medical School, Boston, MA
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Weaver J, Liu KJ. Does normobaric hyperoxia increase oxidative stress in acute ischemic stroke? A critical review of the literature. Med Gas Res 2015; 5:11. [PMID: 26306184 PMCID: PMC4547432 DOI: 10.1186/s13618-015-0032-4] [Citation(s) in RCA: 46] [Impact Index Per Article: 5.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/21/2015] [Accepted: 08/02/2015] [Indexed: 12/22/2022] Open
Abstract
Stroke, one of the most debilitating cerebrovascular and nuerological diseases, is a serious life-threatening condition and a leading cause of long-term adult disability and brain damage, either directly or by secondary complications. Most effective treatments for stroke are time dependent such as the only FDA-approved therapy, reperfusion with tissue-type plasminogen activator; thus, improving tissue oxygenation with normobaric hyperoxia (NBO) has been considered a logical and potential important therapy. NBO is considered a good approach because of its potential clinical advantages, and many studies suggest that NBO is neuroprotective, reducing ischemic brain injury and infarct volume in addition to improving pathologic and neurobehavorial outcomes. However, increased reactive oxygen species (ROS) generation may occur when tissue oxygen level is too high or too low. Therefore, a major concern with NBO therapy in acute ischemic stroke is the potential increase of ROS, which could exacerbate brain injury. The purpose of this review is to critically review the current literature reports on the effect of NBO treatment on ROS and oxidative stress with respect to acute ischemic stroke. Considering the available data from relevant animal models, NBO does not increase ROS or oxidative stress if applied for a short duration; therefore, the potential that NBO is a viable neuroprotective strategy for acute ischemic stroke is compelling. The benefits of NBO may significantly outweigh the risks of potential increase in ROS generation for the treatment of acute ischemic stroke.
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Affiliation(s)
- John Weaver
- Department of Pharmaceutical Sciences, College of Pharmacy, BRaIN Imaging Center, MSC10 5620, 1 University of New Mexico Health Sciences Center, Albuquerque, NM 87131 USA ; Center of Biomedical Research Excellence, College of Pharmacy, University of New Mexico Health Sciences Center, Albuquerque, NM 87131 USA
| | - Ke Jian Liu
- Department of Pharmaceutical Sciences, College of Pharmacy, BRaIN Imaging Center, MSC10 5620, 1 University of New Mexico Health Sciences Center, Albuquerque, NM 87131 USA ; Center of Biomedical Research Excellence, College of Pharmacy, University of New Mexico Health Sciences Center, Albuquerque, NM 87131 USA ; Department of Neurology, University of New Mexico Health Sciences Center, Albuquerque, NM 87131 USA
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